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6. Recognizing possibly more serious headaches

The words ‘serious’ or ‘sinister’ in connection with headaches means to most people making sure that there is not a brain tumour. In fact, a brain tumour is very rarely a cause of headache.

The vast majority of headaches are what we call ‘benign’ – it is rare to find a serious or potentially sinister cause for a headache. We tend to be more concerned about a variety of other ‘secondary’ headaches that occur as a result of other medical conditions or specific structural abnormalities or injuries affecting parts of the brain and associated blood vessels, bones and surrounding structures.

Ruling out a serious headache is about taking a good history and trying to decide if this is a primary headache, such as migraine or cluster headache, or a secondary headache due to a brain tumour, stroke or other medical conditions.

My doctor tells me that my headache symptoms are normal – they are not red flags. What are ‘red flags’?

Red flags’ are the symptoms that may suggest to the doctor that your headache might be due to a more serious or ‘sinister’ underlying cause – a secondary rather than a primary headache.Sometimes these red flags have to be viewed in the context of your previous symptoms and sometimes they are important irrespective of your previous symptoms.

My headache always wakes me in the middle of the night. Should I be worried?

It is often said that a headache that causes you to wake up in the night, rather than a headache you become aware of when you wake in the night, is potentially serious or sinister. As with any ‘rule’ of this type, it is not absolute and needs to be considered in the context of the previous history of headache and any new symptoms that may be developing. Cluster headache tends to occur during the night and will cause you to wake from your sleep. Migraine can also occur in the night, as doe’s hypnic headache, and both will cause you to wake from your sleep.

I always get a really bad headache when I cough or sneeze. Should I do anything about it?

A headache made worse by coughing or sneezing is of no immediate concern. However, a headache that is brought on by coughing and sneezing and is very severe could suggest that there is an underlying structural lesion leading to a rise in cerebrospinal fluid (CSF) pressure within the skull – raised intracranial pressure – and hence causing the headache. When it occurs for the first time, it should be investigated to rule out a structural problem.

If you have had this symptom for months or even years, it is unlikely that there is any cause for concern. If it is something that is more recent and you get a severe headache that stops you dead in your tracks, I would suggest seeking advice from your doctor. If you have had the symptom for some time but it is getting worse and now happens every time rather than some of the time, I would suggest seeing your doctor for advice.

A primary cough headache is a benign headache that happens suddenly and lasts from one second to 30 minutes and is not the result of an underlying structural abnormality. It usually occurs on both sides (bilateral) and tends to affect people over the age of 40.

I am really embarrassed to go and see my doctor because I have started to get headaches when I have sex. My sister says I should go, but I am not so sure. What should I do?

Headaches can occur in a completely benign fashion in association with sexual activity, either during or before orgasm, and are referred to as ‘primary orgasmic’ or ‘coital’ headaches. When this occurs for the first time, it does need investigation and specialist referral to make absolutely sure that there is no structural cause for the headache – to make sure it is not a secondary headache. So you need to forget being embarrassed and go to see your doctor so that you can be referred to a neurologist to be checked out.

Remember that doctors have seen and heard it all before!

I started with headaches a few weeks ago, and they seem to be getting worse very quickly.

I don’t want to waste my doctor’s time. What should I be looking out for?

Headache is always difficult to assess in isolation and needs to be considered in the context of any other symptoms that you might have. If you do not normally get headache symptoms and your headaches seem to be progressing and getting worse over a few days or a few weeks, it would be sensible to go and chat to your doctor to make sure there are no ‘red flag’ symptoms. Your doctor will be able to examine you and make sure there is nothing serious or sinister to find, no physical signs or abnormality, anything that might suggest a secondary headache.

My father was walking along and complained of a severe headache on the back of his head. He couldn’t carry on and a passer-by called for an ambulance. They insisted on taking him to A&E. Why was my father rushed to hospital when he got his headache?

A headache that comes on suddenly and dramatically may be due to a variety of potentially serious and significant structural causes – a secondary headache. The reason for taking him to hospital was to make sure he had not had a subarachnoid haemorrhage (SAH, bleeding onto the surface of the brain). A subarachnoid haemorrhage can occur as a result of:

• The rupture of an aneurysm (a ballooning and weakening of the wall of an artery) or

• An arteriovenous malformation (AVM, the structure of the arteries and veins is abnormal)

Because this can be fatal, a full and complete investigation and assessment is essential.

Headache is the only symptom in 12% of cases of SAH; it happens very suddenly, and is often described as ‘being hit with a hammer’. It is often referred to as a ‘thunderclap headache’. Neck stiffness can take up to three hours to develop, with varying changes in consciousness level occurring. SAH is often a cause of sudden death.

My mother got rushed in to hospital after complaining of a really bad headache, and they spent a lot of time trying to decide whether she should have a CT scan to diagnose a subarachnoid haemorrhage. Can you tell me why?

No test is done without good cause and a reasonable expectation of its providing the information needed to make a diagnosis. A CT scan can make a definite diagnosis of subarachnoid haemorrhage in 98% of cases if it is done within 12 hours of the headache starting. This falls to 93% at 24 hours, 76% at 48 hours and 58% at 5 days. These figures are from studies where expert radiologists read the scans and were able to interpret accurately quite subtle changes (with less skilled radiologists the pick-up rates are substantially lower).

Why did my father have to have a CT scan and a lumbar puncture to rule out a subarachnoid haemorrhage?

A lumbar puncture is done if the CT scan does not give a positive result despite symptoms that indicate SAH. The cerebrospinal fluid (CSF) pressure must be measured at the time that the lumbar puncture is done, to rule out the possibility of the procedure having caused any blood seen in the CSF. The CSF pressure will be raised if there has been a subarachnoid haemorrhage.

I have been told that I have migraine. During the last few attacks I have started getting pins and needles down my left arm. It starts in my hand and seems to move up my arm to my neck. Should I be worried?

Yes and no. It is always difficult to evaluate symptoms, as they need to be set in context. Provided that these sorts of sensory symptoms last for no longer than 60 minutes when they occur with a migraine headache, they are probably migraines in their nature, rather than being due to a secondary cause. Sensory symptoms can extend into the headache phase of the attack but must settle before the headache does.

Symptoms that always occur on the same side may be due to an irritation of the nerve anywhere along its journey from the brain to its end. So, if your symptoms are always on the left side, they may be more likely to need investigating than if either or both sides are affected.

My brother says that his GP reckons that he had a transient ischaemic attack but what he described sounds like my migraine aura. What is the difference between them?

Symptoms of a transient ischaemic attack (TIA; a mini-stroke) can be very similar to those of a migraine aura. The main difference is usually how long they last and the fact that the symptoms of migraine aura are completely and totally reversible, usually over no more than one hour. If it is a TIA, it recovers completely within 24 hours but needs to be taken seriously because it indicates that there is probably something wrong with the blood supply to the brain.

What does the specialist mean by raised intracranial pressure?

He was trying to explain something about why a headache can happen when you cough or strain. The brain and spinal cord are surrounded by fluid called cerebrospinal fluid (CSF). Anything that affects the production, flow or absorption of CSF can lead to changes in intracranial pressure. A rise in pressure can occur with normal physical activities such as coughing or straining but, if there is a structural problem within the brain that affects the flow of CSF, this rise in pressure can be magnified and lead to a headache.

My grandmother has just been diagnosed with temporal arteritis. Can you tell me what that is?

Temporal arteritis is an inflammation in the temporal artery, causing pain that may be felt in the temple, over the forehead or the back of the head and occasionally more generally. The diagnosis may be made from a blood test, but if this is not conclusive, a biopsy of the temporal artery is needed (a tiny sample of the artery is taken for examination under a microscope). Early and prompt treatment is crucial to prevent complications such as blindness. Temporal arteritis is rare in anyone under the age of 55 and becomes more common as each decade passes.

My mother has been put on steroids for her temporal arteritis. How long will she have to be on them?

The response to steroids is swift, but treatment is medium term and is gradually reduced over months to years rather than weeks to months. Steroids have to be taken every day to be effective, and any dose reduction is usually monitored by a blood test. If there is any change in symptoms, following a dose reduction, she will need to increase the dose of steroids, usually for a few weeks before attempting another dose reduction. This is repeated in a step-wise fashion until the steroids have been stopped and all the symptoms have settled.

I think my friend should go to see her doctor . She has been on the Pill for ages but has started getting flashing lights before her usual migraine starts. She says that the flashes last about an hour. She is not worried because her mum gets aura, but I read somewhere that if you have migraine you should not be on the Pill. What should I do?

You need to encourage her to see her doctor to discuss her contraceptive options as, presumably, the last thing she wants is to get pregnant. She may have to stop the Pill she is currently taking, depending on which one it is. There are two different female hormones: oestrogen and progesterone. If she has never had auras before, she should stop any Pill containing oestrogen. Anyone who has aura symptoms should not take a contraceptive Pill containing oestrogen, because of the increased risk of complications.

She can, however, carry on taking her Pill if it just contains progesterone.

Dad has just started to get really bad headaches. He is 55 and smokes. The headaches are always on the same side. Should I make him go and see his doctor?

You should encourage him to see his doctor. Headaches starting in someone over 50 may be benign but the possibility of a structural or secondary cause needs to be ruled out. As a smoker, he is at risk of a variety of conditions that may cause headache symptoms. His doctor will probably do some blood tests, arrange a chest x-ray and possibly refer him to a neurologist for a brain scan.

My cousin had what I thought was the flu, but he then got really bad headaches and was rushed into hospital. What caused his headache?

Any infection can cause headache symptoms, and without more information, or the results of his tests or investigations, I can’t tell you exactly what caused his headache.

If the brain or its membranes become inflamed, you will develop a significant headache that is made worse by light and moving your head (neck stiffness). An inflammation of the brain would be encephalitis and an inflammation of the lining of the brain is called meningitis. The meningeal membranes, which become inflamed, are in three layers: the dura mater, the arachnoid membrane and the pia mater.

A variety of different viruses and bacteria can cause these sorts of infections, some of them more exotic than others. The viruses that cause some forms of encephalitis are associated with particular parts of the world, so a person’s travel history is crucial in making a diagnosis.

What causes meningitis?

Meningitis is an inflammation of the meninges, which is the layer that covers the brain. Meningitis can be caused by a viral infection or a bacterial infection. Meningococcal meningitis is the one that tends to make headlines. Other bacteria can cause meningitis and these include Haemophilus influenzae and Streptococcus pneumoniae. Meningitis, whatever the cause, is a serious condition that needs prompt diagnosis and aggressive treatment.

My uncle has a brain tumour. He started with a weakness of his hand that seemed to get worse and worse. Then his arm got weak, and then his foot started to go funny. What was happening?

Brain tumours may be primary, as a direct result of an abnormality within the brain itself, or secondary, due to the spread of cancerous cells from tumours in other parts of the body. The symptoms your uncle described suggest a tumour because the symptoms developed and progressed over a relatively short time – days and weeks rather than months and years. The symptoms that are seen or experienced are determined by which part of the brain is involved or damaged.

I always thought that you would get a headache if you had a brain tumour but my cousin has been diagnosed with a tumour and he never got a headache once. Why?

Headache is rarely an early symptom in patients with a brain tumour. No more than 20% of people with a brain tumour actually seek advice because of headache symptoms. The difficulty is that primary headaches can occur alongside secondary headaches and the skill of the doctor lies in deciding what the symptoms mean.

A brain tumour is usually recognised by the development of progressive physical symptoms – fits, sensory or motor changes, sometimes emotional or psychological ones – and confirmed by a physical examination and further investigation.

My husband complained of a weakness of his arm. His doctor thought that he had had a mini-stroke when he saw him because it seemed to have got better. Three days later my husband was admitted to hospital because the weakness came back and then got a lot worse. He also found he had difficulty walking. When he was seen in hospital the brain scan showed that he had a brain tumour. Should my doctor have admitted him when he saw him the first time?

It is easy, in retrospect, to feel that a different choice should have been made. As the symptoms had improved by the time your doctor saw your husband, a mini-stroke was the most reasonable and likely cause of your husband’s symptoms initially. This is the difficulty with brain tumours. The diagnosis can only be made as sensory symptoms, such as pins and needles or numbness, or motor symptoms, such as weakness or paralysis, and physical signs, such as an inability to grip or use part of your body, develop and become obvious over time.

It is the speed with which symptoms develop and progress that raises the ‘red flag’ for the doctor. I am sure there was no hesitation in admitting him to hospital when your doctor reviewed your husband, as it became obvious that there was more going on.



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